Benefit Explanation: Virtual Health provided as a means to receive this benefit.
Specialist
CoPay: Not Applicable
CoInsurance: 35.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Virtual Health provided as a means to receive this benefit.
Prescription Drug Information
Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Non Preferred Brand Drugs
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Generic Drugs
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Specialty Drugs
CoPay: Not Applicable
CoInsurance: 30.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Coverage is limited to 30-day supply from preferred specialty pharmacy.
Inpatient Coverage
Hospital Services
CoPay: Not Applicable
CoInsurance: 35.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Coverage for inpatient rehabilitation services are limited to 21 days per calendar year.
Inpatient Services
CoPay: Not Applicable
CoInsurance: 35.00% Coinsurance after deductible
Covered: Covered
Emergency and Urgent Care
Emergency Room
CoPay: Not Applicable
CoInsurance: 35.00% Coinsurance after deductible
Covered: Covered
Urgent Care Facility
CoPay: Not Applicable
CoInsurance: 35.00% Coinsurance after deductible
Covered: Covered
Benefit Explanation: Virtual Health provided as a means to receive this benefit.
Maternity
Labor and Delivery Hospital Stay
CoPay: Not Applicable
CoInsurance: 35.00% Coinsurance after deductible
Covered: Covered
Pre and Postnatal Office Visit
CoPay: $0.00
CoInsurance: Not Applicable
Covered: Covered
Benefit Explanation: Visits 16+ and visits with a perinatologist are subject to the Specialist Visit cost-share.
Vision
Routine Eye Exams For Children
CoPay: $0.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Exam(s) per Year
Benefit Explanation: Covered up through the end of the birth month in which the covered person reaches age nineteen (19).
Major Dental Care
Routine Dental Checkups for Children
CoPay: $0.00
CoInsurance: Not Applicable
Covered: Covered
Limit Quantity: 1
Limit Unit : Visit(s) per 6 Months
Benefit Explanation: Covered up through the end of the birth month in which the covered person reaches age nineteen (19). Basic and major dental care and orthodontic services.
1-817-813-4562, TTY 711
